Provider Demographics
NPI:1881319580
Name:CHACON-DIAZ, RONALDY JOSE
Entity type:Individual
Prefix:
First Name:RONALDY
Middle Name:JOSE
Last Name:CHACON-DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1546 W 59TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-1211
Mailing Address - Country:US
Mailing Address - Phone:323-875-2337
Mailing Address - Fax:
Practice Address - Street 1:4322 WILSHIRE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3737
Practice Address - Country:US
Practice Address - Phone:323-879-4951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY5167594106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician